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the middle ear and this may take the form of tympanoplasty or radical

PROGNOSIS. Chronic tubotympanic infection may cause continuous or
intermittent otorrhoea but is seldom a serious health hazard. It requires
treatment of the upper respiratory tract rather than mastoid surgery. By
intensive local conservative treatment and co-operation of the patient a
majority may obtain a dry ear and in some a successful myringoplasty can
be undertaken. A hard core of patients will continue to have intermittent
aural discharge which with regular toilet of the ear can be an acceptable
condition but they should be advised to report additional symptoms such
as pain, headache or changes in the character of the discharge.

Chronic suppuration in the attic and antrum associated with attic and
posterior marginal perforations of the drumhead constitutes a potentially
serious condition for patients because of the risk of progressive bone
destruction and the spread of the disease to intracranial structures.

Apart from danger to life attico-antral disease causes necrosis of the
ossicles with a progressive and more severe hearing loss, and the purulent
foetid discharge often makes patients seek advice. Persistent purulent dis-
charge in this type of infection indicates an active destructive process requir-
ing surgical treatment. Following radical mastoidectomy or its modified
form a safe dry ear can be expected in 80 per cent of cases. Auditory function
will depend upon the extent to which middle ear mechanisms can be retained
or later reconstructed by tympanoplastic procedures. In many cases a staged
programme is more satisfactory than attempting to eradicate disease and
restore hearing at one operation.

In a small number of cases surgery produces a safe ear although discharge
may persist from the mastoid segment of the cavity and this requires local
medical treatment.


Granulations and polypi are frequently found in chronic suppuration and
much more rarely in acute inflammation. Polypi arise from granulation
tissue which is a poorly differentiated connective tissue. Polypi may grow
from the promontory, the region adjacent to and around the orifice of the
Eustachian tube or the tympanic ring. They may also originate in the attic
spaces and the mastoid antrum. It may be possible, if an inspection of the
drumhead is carried out, to determine from the position of the perforation
the site of origin of the polypus. This information as to the origin of the
polypus has a very important bearing on the chances of recurrence. It
should be quite possible to remove a polypus originating from the promon-
tory or the region of the Eustachian tube so that it will not recur, but those
polypi which arise in the attic spaces and the mastoid antrum are almost
bound to recur because of the great difficulty of access to their roots. One
must expect a recurrence after removal of those polypi which grow from
the tympanic ring because they are arising from caries of the bone in that
site. The distinction between granulations and polypi is somewhat arbitrary.
Granulations are sessile red growths which bleed readily when touched
(see Plate X, 11 and 12). Polypi vary greatly in size and appearance.
They may be little larger than a pin's head or they may entirely fill the